Emergency Ambulance Service Reportable Events: Oct - Dec 2013.
What does the summary of reportable events contain?
The summary contains reportable events and near misses for St John and Wellington Free Ambulance (WFA) where an investigation has been completed. Patient details have been removed to preserve patient confidentiality. Some actions may have been implemented (at the time of reporting) while other actions are yet to be implemented.
How does the number of events compare to the overall service delivered?
Each Quarter approximately 100,000 111 calls are received. Of these, the Ambulance Communication Centre dispatch to around 70,000 emergency incidents. Compared to these volumes the number of events that occur is very low.
Encouraging a culture of safety
Providers encourage their staff to report and log these events. Lessons are learnt and actions are implemented to prevent the event occurring again. The reports contribute to a culture of safety, transparency and continuous improvement.
Where can I get more information?
Information about reportable events and the performance, quality and safety of Emergency Ambulance Services can be found on the NASO website at http://www.naso.govt.nz/home and the Health Quality and Safety Commission website at https://www.hqsc.govt.nz/
For more information about specific events contact St John http://www.stjohn.org.nz/Contact-us/
or Wellington Free Ambulance http://www.wfa.org.nz/contact-us
Clinical management events
# / Provider / Summary of Reportable Event / Root Cause Analysis / Recommendations / Action Taken1 / OSJ / Delay in defibrillation.
Patient cardiac arrested in ambulance close to hospital. CPR commenced and patient defibrillated at hospital. / Poor decision by crew delayed defibrillation.
Patient did not survive; however it appears the patient died from a non-cardiac cause. / Developmental support to assist practice. / Developmental support provided and file noted.
Transport-related events
# / Provider / Summary of Reportable Event / Root Cause Analysis / Recommendations / Action Taken1 / OSJ / Ambulance dispatch error. Job entered as a non-urgent response - sick person. Incident was car versus pedestrian, with a seriously injured patient. / Call taker did not follow procedure to confirm extent of injuries resulting in a non-urgent response.
Do not believe delay impacted patient outcome. / Manager and staff member to review incident. / Developmental support provided.
Equipment-related events
# / Provider / Summary of Reportable Event / Root Cause Analysis / Recommendations / Action Taken1 / OSJ / Suction unit failed during airway management procedure. / Battery failure. No harm occurred to patient. / Review battery replacement programme. / Battery replaced.